Epithelial Root Sheath Research Articles

Radicular invaginatus caused by the developmental abnormalities of epithelial root sheath

Epithelial root sheath plays a key role in guiding the development of tooth root. Any problems during its growth can lead to various forms of defects or abnormalities in the development of tooth root. Radicular invaginatus may occur when the epithelial root sheath excessively proliferates and infolds into the dental papilla. In terms of tissue origin and occurrence mechanism, the radicular dens invaginatus is similar to the coronal invaginatus which is led by the proliferation and infolding of enamel organ. However, there had been no consensus on the term and classification of this type of developmental abnormality as well as the relationships among the dens invaginatus, the radicular invaginatus and the palatogingival groove. From the role of epithelial root sheath during root development, the manifestations of root developmental defects and abnormalities will be analyzed. The pathogeny, classification, clinical characteristics of the radicular invaginatus, the relationship with the dens invaginatus and the impact on treatment were specially focused on.

Semaphorin-RhoA signaling regulates HERS maintenance by acting against TGF-β-induced EMT.

Hertwig's epithelial root sheath (HERS) plays a role in root dentin formation. It produces the epithelial rests of Malassez (ERM) for the induction of periodontal tissue development during root formation. Although ERM is thought to be caused by epithelial-mesenchymal transition (EMT), the mechanism by which HERS is maintained as epithelium is unknown. Here, we aimed to elucidate the molecular mechanisms regulating the relationship between HERS maintenance and ERM development. To understand the relationship between HERS and ERM development during root formation, we observed the developing molar root using cytokeratin14 (CK14) Cre/tdTomato mice via stereomicroscopy. The relationship between semaphorin and transforming growth factor (TGF) signaling in the maintenance of HERS and ERM development was examined using CK14cre/R26-tdTomato mice and a HERS cell line. tdTomato-positive cells were observed on HERS and the migrating cells from HERS. The migrating cells showed reduced E-cadherin expression. In contrast, HERS cells expressed semaphorin receptors and active RhoA. Semaphorin signaling was associated with RhoA activation and cell-cell adhesion, while TGF-β induced decreased E-cadherin and active RhoA expression, and consequently enhanced cell migration. HERS induces root formation by controlling epithelial maintenance and EMT through the opposing effects of semaphorin and TGF-β signaling.

Apical Papilla Regulates Dental Follicle Fate via the OGN-Hh Pathway

Root apical complex, including Hertwig’s epithelial root sheath, apical papilla, and dental follicle (DF), is the germinal center of root development, wherein the DF constantly develops into periodontal tissue. However, whether DF development is regulated by the adjacent apical papilla remains largely unknown. In this study, we employed a transwell coculture system and found that stem cells from the apical papilla (SCAPs) inhibit the differentiation and maintain the stemness of dental follicle stem cells (DFSCs). Meanwhile, partial SCAP differentiation markers were upregulated after DFSC coculture. High-throughput RNA sequencing revealed that the Hedgehog (Hh) pathway was significantly downregulated in DFSCs cocultured with SCAPs. Upregulation or downregulation of the Hh pathway can respectively activate or inhibit the multidirectional differentiation of DFSCs. Osteoglycin (OGN) (previously known as mimecan) is highly expressed in the dental papilla, similarly to Hh pathway factors. By secreting OGN, SCAP regulated the stemness and multidirectional differentiation of DFSCs via the OGN-Hh pathway. Finally, Ogn–/– mice were established using the CRISPR/Cas9 system. We found that the root length growth rate was accelerated during root development from PN0 to PN30 in Ogn–/– mice. Moreover, the hard tissues (including dentin and cementum) of the root in Ogn–/– mice were thicker than those in wild-type mice. These phenotypes were likely due to Hh pathway activation and the increased cell proliferation and differentiation in both the apical papilla and DF. The current work elucidates the molecular regulation of early periodontal tissue development, providing a theoretical basis for future research on tooth root biology and periodontal tissue regeneration.

Hertwig's epithelial root sheath cells show potential for periodontal complex regeneration.

Although researchers have been exploring therapeutic strategies of treating serious periodontal tissue loss, including the application of stem cells, tissue regeneration of the periodontal complex involving cementum, periodontium, and alveolar bone has hardly been achieved. Aiming at tackling the problem of severely damaged periodontal complex, it is worth trying to make advantages of Hertwig's epithelial root sheath (HERS) cells to tissue regeneration mimicking the physiological developmental process with their ability of cementum, bone, and periodontium formation. HERS cells and dental follicle cells (DFCs) were acquired from Sprague Dawley rats' molar germs and identified by immunofluorescence. Alizarin red assay, ALP staining, AKP test, real-time quantitative polymerase chain reaction (RT-qPCR) and Western blot were conducted to confirm the osteogenic potential, epithelial-mesenchymal transition (EMT) character of harvested HERS cells and epithelial-mesenchymal interaction (EMI) with DFCs. An animal model of periodontal defect was constructed to testify the tissue regeneration ability in vivo. Micro-CT and histological examinations were interpreted to unveil the tissue repair outcomes. HERS cells expressed strong epithelial cell markers CK14 and E-cadherin. The in vitro experiments overall showed the concretely enhanced osteogenic differentiation ability in either HERS group or HERS+DFC group. Meanwhile, the in vivo conduction of rat mandibular periodontal repair experiment showed regenerative effectiveness of periodontal complex structure in both HERS and HERS+DFC group in situ, testified by Micro-CT and histological analysis. HERS cells show potential for periodontal tissue regeneration which suggests the future possibilities of being considered as one of the cell choices for severely damaged periodontal tissue repair.

The Effect of Etiology on the Function of Hertwig\'s Epithelial Root Sheath in Regenerative Endodontic Procedures—A Review of Literature

AbstractThe management of nonvital immature permanent teeth poses quite a challenge. The apexification procedure is in use for long-term now but the treated teeth are more prone to fracture questioning the long-term prognosis of this technique. The introduction of regenerative procedures for the treatment of these teeth is quite favorable; however, despite the increasing use of regenerative endodontic therapy procedures, inconsistent results are seen in the root development. Conservation of Hertwig's epithelial root sheath may have a prime role and selecting the cases with viable root sheath may impact on the consistent positive results treated with regenerative procedures. This article aims to look at the database to find the role of etiology and its implication on Hertwig's epithelial root sheath in the outcome of regenerative endodontics.

LB890 Cyclic hair growth requires spatiotemporal heterogeneity in hair follicle signaling network

Hair follicles (HFs) are cyclically growing skin mini-organs, that oscillate between small, telogen and large, anagen sizes and form hair fibers of variable length. Although cellular lineages and spatial distribution of HF cell types are largely defined, the dynamic molecular events controlling HF size and hair fiber length remain elusive. We developed a multi-scale mathematical model of HF, that permits computational testing of its growth behavior. Our model predicts that epithelial outer root sheath (ORS) cells need to develop signaling heterogeneity to one or more paracrine pathways for a HF to achieve and maintain its steady-state size in anagen and to not become excessively long, snake-like.

3D-bioprinted Recombination Structure of Hertwig's Epithelial Root Sheath Cells and Dental Papilla Cells for Alveolar Bone Regeneration.

Three-dimensional (3D) bioprinting is an emerging method for tissue regeneration. However, promoting the epithelial-mesenchymal interaction (EMI), while maintaining the characteristics of epithelial cells has always been a challenge in tissue engineering. Since EMI acts as a critical factor in bone regeneration, this study aims to promote EMI by recombining epithelial and mesenchymal cells through 3D bioprinting. Hertwig’s epithelial root sheath (HERS) is a transient structure appeared in the process of tooth root formation. Its epithelial characteristics are easy to attenuate under appropriate culture environment. We recombined HERS cells and dental papilla cells (DPCs) through 3D bioprinting to simulate the micro-environment of cell-cell interaction in vivo. HERS cells and DPCs were mixed with gelatin methacrylate (GelMA) separately to prepare bio-inks for bioprinting. The cells/GelMA constructs were transplanted into the alveolar socket of Sprague-Dawley rats and then observed for 8 weeks. Hematoxylin and eosin staining, Masson staining, and immunohistochemical analysis showed that dimensional cultural pattern provided ideal environment for HERS cells and DPCs to generate mineralization texture and promote alveolar bone regeneration through their interactions. 3D bioprinting technology provides a new way for the co-culture of HERS cells and DPCs and this study is inspiring for future research on EMI model.

Effect of systemic antibiotic therapy on pulp repair following extrusive luxation and avulsion in a murine model: A histomorphological study.

The evidence for any benefit of systemic antibiotic therapy on pulp survival following extrusive luxation and avulsion is inconclusive. The aim of this study was to evaluate the effect of systemic antibiotic therapy with amoxycillin and tetracycline for 7 days on different aspects of dental pulp repair in a murine model. The right maxillary incisor of 180 4 to 8-week-old male Wistar rats underwent extrusive luxation or avulsion. The animals were then treated with saline solution (control), tetracycline, or amoxicillin administered intra-gastrically for 7 days, and euthanized at 7, 15, and 30 days post-operatively. The layer of odontoblast cells, reparative dentin deposition, Hertwig's epithelial root sheath, pulp necrosis, and periapical inflammatory infiltrate were histomorphologically analyzed and scored. Mann-Whitney, Kruskal-Wallis, and Dunn tests were used to compare mean scores for the different procedures, treatments, and times (p ≤ .05). Significant differences were observed between luxated and avulsed teeth (p < .05). In luxated teeth, no differences were observed among treatments and times, except for more tertiary dentin deposition in the coronal third with the use of tetracycline compared with amoxicillin at 15 days (p < .05). In avulsed teeth, higher scores for the layer of odontoblast cells and lower scores for periapical inflammatory infiltrate at 7 days and pulp necrosis at 7 and 15 days were observed in the amoxicillin group compared to the saline and tetracycline groups (p < .05). At 30 days, however, no differences were observed among treatments. The use of systemic antibiotic therapy with tetracycline or amoxicillin for 7 days did not contribute to pulp repair following extrusive luxation or avulsion in rats. However, the results warrant further research into the use of amoxicillin for a more extended period of time in cases of avulsion.

Enamel Matrix Derivatives for Periodontal Regeneration: Recent Developments and Future Perspectives.

In the era of the growing population, the demand for dental care is increasing at a fast pace for both older and younger people. One of the dental diseases that has attracted significant research is periodontitis. Periodontal therapy aims to regenerate tissues that are injured by periodontal disease. During recent decades, various pioneering strategies and products have been introduced for restoring or regeneration of periodontal deficiencies. One of these involves the regeneration of tissues under guidance using enamel matrix derivatives (EMDs) or combinations of these. EMDs are mainly comprised of amelogenins, which is one of the most common biological agents used in periodontics. Multiple studies have been reported regarding the role of EMD in periodontal tissue regeneration; however, the extensive mechanism remains elusive. The EMDs could promote periodontal regeneration mainly through inducing periodontal attachment during tooth formation. EMD mimics biological processes that occur during periodontal tissue growth. During root development, enamel matrix proteins are formed on the root surface by Hertwig's epithelial root sheath cells, initiating the process of cementogenesis. This article reviews the challenges and recent advances in preclinical and clinical applications of EMDs in periodontal regeneration. Moreover, we discuss the current evidence on the mechanisms of action of EMDs in the regeneration of periodontal tissues.

Radicular Dens Invaginatus

Dens invaginatus is an anomaly of the shape of teeth resulting from invagination of the developing tooth germ. Although the coronal variant is frequently observed in the clinical setting, the true “radicular” variant of Dens invaginatus resulting from invagination of the Hertwig's epithelial root sheath at the root level is extremely rare. The anomaly can present in itself with multiple sequelae owing to the peculiar structure of the tooth which makes it vulnerable for entry and lodging of bacteria even in a tooth with an apparently normal crown devoid of any carious process. It also complicates the treatment plan whereby it renders root canal treatment impracticable and makes it difficult to extract the tooth atraumatically. The present report consists of one such case of radicular dens invaginatus that was diagnosed by correlating clinical, radiographic, and histopathological findings. Management of the case was done by extracting the tooth in multiple sections without any posttreatment complications.

Gene and protein interaction network analysis in the epithelial-mesenchymal transition of Hertwig's Epithelial Root Sheath reveals periodontal regenerative drug targets – An in silico study

Background and aimHertwig’s Εpithelial Root Sheath (HΕRS) has a major function in the developing tooth roots. Earlier research revealed that it undergoes epithelial–mesenchymal transition, a vital process for the morphogenesis and complete development of the tooth and its surrounding periodontium. Few studies have demonstrated the role of HERS in cementogenesis through ΕMΤ. The background of this in-silico system biology approach is to find a hub protein and gene involved in the EMT of HERS that may uncover novel insights in periodontal regenerative drug targets. Materials and methodsThe protein and gene list involved in epithelial–mesenchymal transition were obtained from literature sources. The protein interaction was constructed using STRING software and the protein interaction network was analyzed. Molecular docking simulation checks the binding energy and stability of protein-ligand complex. ResultsResults revealed the hub gene to be DYRK1A(Hepcidin), and the ligand was identified as isoetharine. SΤRIΝG results showed a confidence cutoff of 0.9 in sensitivity analysis with a condensed protein interaction network. Overall, 98 nodes from 163 nodes of expected edges were found with an average node degree of 11.9. Docking results show binding energy of −4.70, and simulation results show an RMSD value of 5.6 Å at 50 ns. ConclusionIsoetharine could be a potential drug for periodontal regeneration.

Pulp Revascularization and Regeneration: Differences, Utilization, and Outcome

Microbial, mechanical, physical, and chemical factors are strong enough to endanger tooth pulp, resulting in alterations and inflammation of its vasculature, and causing intolerable pain. Clinical and technical management of diseases of these tissues is oftentimes very difficult due to the vastly varied anatomical nature of the pulpal space. Root canal treatment has been used to scavenge the diseased pulp and allow healing of the supporting tissues. In a small proportion of teeth, the creation of the apical root structure Hertwig’s Epithelial Root Sheath may not be completed (causing an open apex) because of trauma or breach of the pulp by caries. In these scenarios, alternative techniques have been found, which regenerate a functional pulp tissue optimally. Regenerative endodontic procedures are biologically based techniques devised for predictable replacement of injured, infected, or missing structures with live viable tissues that restore the normal physiologic functions of the pulpdentine complex. Pulp revascularization is generally described as re-introduction of vascularity in the root canal system. Pulp regeneration, on the contrary, has not been accurately defined. Even though blood vessels are necessary components of dental pulp, pulpal regeneration is regarded incomplete without an odontoblastic layer bordering the dentin-pulp interface. Although the interactions with human pulp derived stem cells are still vague, it is suspected that conventional pulpal cells that resist infection can grow rapidly under the impact of Hertwig’s epithelial root sheath even during the inflammation stage; generating odontoblasts which has the ability to give rise to a tubular dentin, triggering apexogenesis. It is understood that similar and consistent outcomes in the endodontics are not always achieved. The pace of apex maturogenesis differs due to distinctive conditions of each case. A possibility of chronic necrosis my strip the pulpal tissue of remnants of viable cells and may lead to reduced capabilities to regenerate.

Orthodontic tooth movement alters cementocyte ultrastructure and cellular cementum proteome signature.

Cementum is a mineralized tissue that covers tooth roots and functions in the periodontal attachment complex. Cementocytes, resident cells of cellular cementum, share many characteristics with osteocytes, are mechanoresponsive cells that direct bone remodeling based on changes in loading. We hypothesized that cementocytes play a key role during orthodontic tooth movement (OTM). To test this hypothesis, we used 8-week-old male Wistar rats in a model of OTM for 2, 7, or 14days (0.5N), whereas unloaded contralateral teeth served as controls. Tissue and cell responses were analyzed by high-resolution micro-computed tomography, histology, tartrate-resistant acid phosphatase staining for odontoclasts/osteoclasts, and transmission electron microscopy. In addition, laser capture microdissection was used to collect cellular cementum, and extracted proteins were identified by liquid chromatography coupled to tandem mass spectrometry. The OTM model successfully moved first molars mesially more than 250μm by 14days introducing apoptosis in a small number of cementocytes and areas of root resorption on mesial and distal aspects. Cementocytes showed increased nuclear size and proportion of euchromatin suggesting cellular activity. Proteomic analysis identified 168 proteins in cellular cementum with 21 proteins found only in OTM sites and 54 proteins only present in control samples. OTM-down-regulated several extracellular matrix proteins, including decorin, biglycan, asporin, and periostin, localized to cementum and PDL by immunostaining. Furthermore, type IV collagen (COL14A1) was the protein most down-regulated (-45-fold) by OTM and immunolocalized to cells at the cementum-dentin junction. Eleven keratins were significantly increased by OTM, and a pan-keratin antibody indicated keratin localization primarily in epithelial remnants of Hertwig's epithelial root sheath. These experiments provide new insights into biological responses of cementocytes and cellular cementum to OTM.

Epithelial Cell Rests of Malassez Provide a Favorable Microenvironment for Ameliorating the Impaired Osteogenic Potential of Human Periodontal Ligament Stem Cells.

Human periodontal ligament stromal/stem cells (PDLSCs) are ideal candidates for periodontal regeneration and are of significant importance in clinical practice. However, PDLSCs derived from diseased microenvironments exert impaired behavior, which leads to the failure of periodontal regeneration. The epithelial cell rests of Malassez (ERM), which are involved in periodontal homeostasis, are residual cells from Hertwig's epithelial root sheath (HERS). However, the function of ERM remains largely unknown. Therefore, the aim of this study was to evaluate the effect of ERM on the osteogenic potential of PDLSCs from an impaired microenvironment. PDLSCs from healthy donors (H-PDLSCs), periodontitis donors (P-PDLSCs) and human ERM were harvested. Osteogenic evaluation showed a lower osteogenic potential of P-PDLSCs compared to that of H-PDLSCs. Then, we co-cultured ERM with P-PDLSCs, and the data showed that ERM promoted the expression of osteogenic genes and proteins in P-PDLSCs. In addition, we collected the PDLSCs from aged donors (A-PDLSCs) and analyzed the osteogenesis capacity of the A-PDLSCs and A-PDLSCs + ERM groups, which displayed similar results to P-PDLSCs. Finally, we evaluated the Wnt pathway, which is associated with osteogenic differentiation of stromal/stem cells, in A-PDLSCs + ERM and P-PDLSCs + ERM groups, which indicated that suppression of the Wnt pathway may result in an increase in the osteogenic properties of A-PDLSCs + ERM and P-PDLSCs + ERM groups. Taken together, the above findings shed new light on the function of ERM and provide a novel therapeutic for optimizing PDLSCs-based periodontal regeneration.

Signaling Modulation by miRNA-221-3p During Tooth Morphogenesis in Mice.

miRNAs are conserved short non-coding RNAs that play a role in the modulation of various biological pathways during tissue and organ morphogenesis. In this study, the function of miRNA-221-3p in tooth development, through its loss or gain in function was evaluated. A variety of techniques were utilized to evaluate detailed functional roles of miRNA-221-3p during odontogenesis, including in vitro tooth cultivation, renal capsule transplantation, in situ hybridization, real-time PCR, and immunohistochemistry. Two-day in vitro tooth cultivation at E13 identified altered cellular events, including cellular proliferation, apoptosis, adhesion, and cytoskeletal arrangement, with the loss and gain of miRNA-221-3p. qPCR analysis revealed alterations in gene expression of tooth-related signaling molecules, including β-catenin, Bmp2, Bmp4, Fgf4, Ptch1, and Shh, when inhibited with miRNA-221-3p and mimic. Also, the inhibition of miRNA-221-3p demonstrated increased mesenchymal localizations of pSMAD1/5/8, alongside decreased expression patterns of Shh and Fgf4 within inner enamel epithelium (IEE) in E13 + 2 days in vitro cultivated teeth. Moreover, 1-week renal transplantation of in vitro cultivated teeth had smaller tooth size with reduced enamel and dentin matrices, along with increased cellular proliferation and Shh expression along the Hertwig epithelial root sheath (HERS), within the inhibitor group. Similarly, in 3-week renal calcified teeth, the overexpression of miRNA-221-3p did not affect tooth phenotype, while the loss of function resulted in long and slender teeth with short mesiodistal length. This study provides evidence that a suitable level of miRNA-221-3p is required for the modulation of major signaling pathways, including Wnt, Bmp, and Shh, during tooth morphogenesis.

Diagnosis &amp; Management of Labiogingival Groove: A Case Report

Labiogingival groove is a congenital morphologic dental anomaly, in which an infolding of the inner enamel epithelium and Hertwig's epithelial root sheath create a groove extending varying depth into root. Epithelial attachment can be breached by gingival irritation secondary to plaque accumulation creating a periodontal defect. A 24-year-old boy reported with the complaint of a dull gnawing pain from labial gingival surface in the maxillary left central incisor for 2 to 3 months. Intraoral examination revealed inflamed gingiva with loss of contour in relation to maxillary left central incisor. A diagnosis of localised periodontitis was given and required treatment was carried out. On exposure of the involved tooth, a labiogingival groove was noticed which could have been a contributing factor for the increased disease activity at the concerned site.

Epithelial Bone Morphogenic Protein 2 and 4 Are Indispensable for Tooth Development.

The Bmp2 and Bmp4 expressed in root mesenchyme were essential for the patterning and cellular differentiation of tooth root. The role of the epithelium-derived Bmps in tooth root development, however, had not been reported. In this study, we found that the double abrogation of Bmp2 and Bmp4 from mouse epithelium caused short root anomaly (SRA). The K14-cre;Bmp2f/f;Bmp4f/f mice exhibited a persistent Hertwig’s Epithelial Root Sheath (HERS) with the reduced cell death, and the down-regulated BMP-Smad4 and Erk signaling pathways. Moreover, the Shh expression in the HERS, the Shh-Gli1 signaling, and Nfic expression in the root mesenchyme of the K14-cre;Bmp2f/f;Bmp4f/f mice were also decreased, indicating a disrupted epithelium- mesenchyme interaction between HERS and root mesenchyme. Such disruption suppressed the Osx and Dspp expression in the root mesenchyme, indicating an impairment on the differentiation and maturation of root odontoblasts. The impaired differentiation and maturation of root odontoblasts could be rescued partially by transgenic Dspp. Therefore, although required in a low dosage and with a functional redundancy, the epithelial Bmp2 and Bmp4 were indispensable for the HERS degeneration, as well as the differentiation and maturation of root mesenchyme.

Local Irradiation of Mouse Tooth Germ Gives Insight into the Direct Effects of Irradiation on Root Development.

To elucidate the mechanism underlying the failure of root formation after irradiation, we established a method of local irradiation of the molar tooth germ and demonstrated that radiation directly affected dental root development. In the current study, to locally irradiate the lower first molars of 5-day-old C57BL/6J mice, we used lead glass containing a hole as a collimator. We confirmed that our local irradiation method targeted only the tooth germ. The irradiated root was immature in terms of apical growth, and dentin formation was irregular along the outside of the root apices. Moreover, calcified tissue apically surrounded Hertwig's epithelial root sheath, which disappeared abnormally early. This method using a local irradiation experimental model will facilitate research into radiation-induced disorders of dental root formation.

Expressions of cytokeratin 14 and proliferating cell nuclear antigen in the Hertwig's epithelial root sheath of a Vps4b knockout mouse.

The effect of Vps4b gene mutation on the expressions of cytokeratin 14 (CK14) and proliferating cell nuclear antigen (PCNA) in the Hertwig's epithelial root sheath (HERS) is investigated. The bilateral mandibular tissues of mouse on postnatal days 5, 9, 11, 15, and 19 were removed. The mandibular first molar tissue sections were obtained after paraffin embedding. The CK14 and PCNA expressions in the epithelial root sheath of the normal mouse and Vps4b knockout mouse were compared through immunohistochemistry. On postnatal day 5, the normal mouse began to form HERS and had a strong positive PCNA expression in the HERS cells; on postnatal day 9, the HERS structure was continuous, and PCNA was positive in the HERS cells; on postnatal day 11, a small portion of HERS began to break, and PCNA was weakly positive in the HERS cells; on postnatal day 15, HERS continued to fracture; PCNA was weakly and positively expressed in the HERS cells on the root surface; on postnatal day 19, the tooth root reached normal physiological length, and PCNA was positively expressed in the HERS cells of the terminal part. Similar to the normal mouse, the gene knockout mouse also formed a HERS structure on postnatal day 5. However, HERS began to break on postnatal day 9. On postnatal day 19, only a few fragments of HERS were found on the root surface, and the root development was immature. Moreover, the expression intensity of PCNA in the gene knockout mouse was decreased. The Vps4b gene mutation may change the CK14 and PCNA expressions, leading to abnormal root development.

An unusual case of incomplete healing with intraosseous fibrous scar formation in the surgically enucleated site associated with a Type II dens invaginatus: A 4-year follow-up case report

Dens invaginatus is a developmental deformation with varying anatomical features, caused by the envelopment of the enamel organ and/or the Hertwig’s epithelial root sheath within the tooth before calcification completes, increasing the vulnerability of pulpal and periodontal inflammation, posing challenges to treatment, and adequate healing. Cell rest of Malassez, remnants of enamel organ or root sheet may cause cystic lesion formations, also hinder the normal healing process and form a fibrous scar. Intraosseous fibrous scar is a result of incomplete wound healing after periradicular surgery which mimics an asymptomatic residual cyst clinically and radiographically. We herein report a case of a surgically managed an immature maxillary lateral incisor affected with Type II dens invaginatus associated with incomplete periradicular healing presented as intraosseous fibrous scar with a persistent well-defined radiolucency between the healthy trabecular bone. The regular clinical and radiographic follow-up records the asymptomatic endodontically treated dens invaginatus with an intact lamina dura and regular healing trabecular bone pattern. Its 4 years of post-operative evaluation has been presented. Features of this case, causes of such incomplete healing, diagnosis, treatment line, prognosis, and the dilemma of the clinician are discussed together with its probable implications.